EXECUTIVE SUMMARY

With data showing continued increases in the use of antibiotics, even in cases in which such prescribing is unnecessary and ill-advised, both the CDC and TJC are pushing initiatives aimed at improving antibiotic stewardship. The initiatives stress the importance of patient and provider education, the tracking of antibiotic use and resistance, and the need for top-level support. Although smaller hospitals face challenges in meeting the new standards, some health systems are getting around the problem through the use of telemedicine.

  • The CDC is pushing hospitals to implement seven core elements that the agency maintains are critical to an effective antibiotic stewardship program.
  • TJC has established a new standard requiring all hospitals to create antibiotic stewardship programs that are steered by a multidisciplinary team.
  • Intermountain Healthcare in Salt Lake City is helping smaller hospitals in its network meet these new TJC and CDC directives by supplying support and expertise via telemedicine.
  • The telehealth program also enables both emergency and inpatient providers to access infectious disease expertise when patients present with issues of concern.

Realizing, with some alarm, that U.S. hospitals continue overusing antibiotics, threatening their effectiveness over the long term, health policy organizations and accrediting agencies are pushing initiatives aimed at educating providers on the risks of overuse and encouraging them to adjust their practices to ensure that antibiotics are used only when appropriate. TJC has implemented a new standard of antibiotic stewardship for accredited hospitals, and the CDC continues to push for the implementation of core elements it maintains are essential to effective antibiotic stewardship.

Speaking about this issue during a teleconference on Jan. 11, Arjun Srinivasan, MD, the associate director for healthcare-associated infection prevention programs in the Division of Healthcare Quality Promotion at the CDC, underscored the point that antibiotics are fundamentally different from all other medications.

“Antibiotics are a class of drugs that lose their effectiveness over time, even if we use them perfectly,” he said. “They are a shared resource, and the use of antibiotics in one person can impact how well they might work in someone else.”

Srinivasan noted that although almost every specialty uses antibiotics on a regular basis, exposure to these drugs comes with risks, regardless of whether the antibiotics have been used appropriately.

“The side effects from antibiotics are many and they are significant,” he said. “We know that being exposed to an antibiotic confers a selective pressure for resistance. It also creates a risk for fungal blood stream infections.”

Patients who receive antibiotics also are at significant increased risk for Clostridium difficile infection for up to three months post exposure, and antibiotics are a frequent cause of adverse drug reactions in both inpatient and outpatient settings, Srinivasan added. In fact, he noted that adverse reactions to antibiotics result in about 140,000 visits to the ED every year.

“All of these adverse events and side effects would be things that we would accept as the price of doing business in cases where the antibiotic exposure is necessary. If the patient needs an antibiotic, then we just have to accept the fact that there are going to be potential consequences, and we need to monitor those,” he said. “The problem, of course, is that in many instances the exposure to an antibiotic is completely unnecessary. In those circumstances, when a patient gets an antibiotic when they don’t need one, we are exposing them to all of the potential downsides of antibiotics with no potential benefit.”

Such instances are not rare. Srinivasan noted that multiple studies suggest that roughly one-third of the antibiotics prescribed in both inpatient and outpatient settings are unnecessary. Specifically, he cited three of the most common ways that antibiotics tend to be overprescribed: The duration of therapy is longer than recommended; antibiotics are prescribed to treat noninfections or nonbacterial syndromes; and antibiotics are used to treat a positive culture result when the patient does not have an infection.

Srinivasan emphasized that providers must understand that improved antibiotic stewardship offers immediate benefits to patients.

“We are not trying to improve antibiotic use for some down-the-road, theoretical, societal benefit,” he said. “We are doing this because it has a direct and positive impact on the patients in the beds in front of [providers]. Improving antibiotic use has direct benefits to individual patients.”

For example, Srinivasan said that published data demonstrate that improved antibiotic stewardship can lead to higher infection cure rates, lower rates of side effects (such as Clostridium difficile), lower rates of developing subsequent resistant infections in a difficult-to-treat patient during a single hospitalization, and possibly even reduced mortality.

However, there is ample room for improvement in this area. Srinivasan pointed to one recent study showing just how frequently antibiotics are prescribed in the inpatient setting.1

“What we found in this study is that just over half of all patients who were admitted to a U.S. hospital get at least one dose of an antibiotic during their stay,” he said. “The overall use was about 755 days of therapy per thousand patient days, so 75% of all days in the hospital involved an antibiotic. And that rate didn’t change between 2006 and 2012.”

Further, Srinivasan noted that the data didn’t vary by bed size. Antibiotic use was just as common in small hospitals as it was in large hospitals. In fact, he noted that nonteaching hospitals demonstrated higher rates of antibiotic use than teaching hospitals. What’s more, while the use of some classes of antibiotics decreased between 2006 and 2012, usage of other classes increased during this period — significantly, in some cases.

“What was both interesting and concerning about these increases was that they tended to come in many of the most broad spectrum classes,” Srinivasan said.

For example, he noted that vancomycin use was up by 32%, beta-lactam/inhibitor use was up by 26%, third- and fourth-generation cephalosporins use increased by 12%, and carbapenem use rose by 37% during the study period.

Implement Core Elements

To make progress on appropriate antibiotic use, the CDC has outlined seven core elements that the agency believes are critical pieces to an effective antibiotic stewardship program. These include:

  • top-level commitment, including resources and support from administrators;
  • accountability with a single leader who is responsible for outcomes;
  • drug expertise with a single pharmacy leader;
  • specific actions or improvement interventions;
  • tracking antibiotic use and resistance patterns;
  • ongoing reporting on antibiotic use and resistance to providers, nurses, and relevant staff;
  • education for clinicians on antibiotic use and resistance. (http://bit.ly/2jDrLvZ)

Srinivasan noted that the CDC core elements are in close alignment with TJC’s new antibiotic stewardship standard, effective as of Jan. 1, 2017, requiring accredited hospitals to create antibiotic stewardship programs, although TJC’s standard specifically requires hospitals to establish an antimicrobial stewardship multidisciplinary team that includes an infectious disease physician, infection preventionist, pharmacist, and a practitioner. TJC’s standard also calls on hospitals to educate patients and families, when needed, on the appropriate use of antibiotics. (http://bit.ly/2ksi1sB)

Consider Challenges

Although meeting the requirements spelled out in both the CDC’s core elements and TJC’s new standard on antimicrobial stewardship may not present undue challenges for large, academic medical centers that have the requisite resources in house, it is a much taller order for smaller facilities, many of which are not equipped with the resources or expertise to properly execute stewardship programs.

To get around this problem, Salt Lake City-based Intermountain Healthcare is leveraging its existing telehealth infrastructure to provide the expertise and support that these smaller hospitals need to both meet the antimicrobial stewardship goals and to improve patient care. At press time, the Infectious Diseases Telehealth Program had been deployed at three of the health system’s community hospitals, with plans to bring the remaining small hospitals in the network on board by April, explained Todd Vento, MD, MPH, FACP, FIDSA, medical director of Infectious Diseases Telehealth Services at Intermountain Healthcare.

The telehealth program provides two key components: access to full consultations with an infectious disease specialist via a telehealth platform so that the remote provider can view and interact with patients, and a telephone-based hotline that is available on a 24/7 basis to providers seeking advice from infectious disease specialists on any matter regarding diagnostics, therapeutics, or antibiotic decision-making for an infectious disease.

Fully Leverage Expertise

Vento noted that the bulk of the calls that the program receives involve bread-and-butter infectious diseases such as complicated pneumonia or prosthetic joint infections.

“One of the most important conditions we get called on is to help with the management of patients with bacteremia,” he explained. “A lot of times, especially with bacteremia, there are other things that the referring providers maybe aren’t aware of. While they present the case to us, we guide them on other diagnostic studies that may be required to make sure [the patient] doesn’t have downrange effects.”

On occasion, participants in the program hear about a patient with an unusual diagnosis. For example, Vento noted that he recently was consulted on a case involving a patient who presented with a fever to the ED at one of Intermountain Healthcare’s community hospitals, and the provider called into the program for guidance.

“The provider just wanted to make sure he wasn’t missing anything in terms of travel and where the patient had been,” Vento said. “We ended up making some recommendations, and the patient was diagnosed with malaria even though it was 10 degrees outside and he was on a ski vacation. Because of his prior travel, he had exposure and infection with malaria.”

The infectious disease experts first consulted with the ED providers by phone, and later worked with the hospitalists to guide them through all the diagnostic recommendations, and alerted them to potential complications that could develop, Vento noted.

“Because of the telehealth support, we were able to manage that patient without having him transferred to a larger facility, which would have been a big inconvenience for the patient,” he said. “We treated the case of malaria successfully basically by putting this subject matter expertise far forward by using the telehealth technology.”

Educate Patients, Staff

On those occasions when a remote infectious disease provider interacts with a patient, the provider uses the opportunity to explain the benefits and risks associated with antibiotics.

“Any time we talk about any antimicrobial therapy, whether or not we are using it, we get to educate the patient, and that is another moment in time in the care of the patient, particularly a hospitalized patient, when they can get that additional advice,” Vento observed. “We counsel every patient who is on antimicrobial therapy on indications for the therapy as well as contraindications, the risks and benefits, and also the adverse effects.”

Vento noted that it is not unusual for this education to extend to the nurses and other staff caring for the patient. “This is an added layer of education specifically targeting antimicrobial use,” he said.

Of course, putting resources in place doesn’t mean that providers will use them. Consequently, Vento offered that telehealth program representatives engage in extensive outreach with participating hospitals.

“We go to the sites, meet the personnel at each of the facilities, and then describe the program to them so that they realize it is an added service that they can take advantage of,” Vento related. “We meet with the providers who will be using the services so that they are fully aware of how to arrange consults.”

Establish Multidisciplinary Team

As part of the telehealth program, Intermountain Healthcare also offers a third component, which includes formal stewardship support services to ensure that the participating hospitals are in compliance with TJC requirements.

“We identify at these facilities a physician champion, a pharmacist champion, a quality committee or a quality representative, as well as an infection preventionist from the hospital,” Vento observed. “We have also asked them to have nursing involved as well.”

The telehealth program complements the facility’s onsite team with a remote infectious disease physician and an infectious disease pharmacist from Intermountain Healthcare’s central facility.

“We then show them their antibiogram data, their antibiotic use data, and then really empower them with our support and expertise,” Vento said. “We let them run as an organization so that they essentially identify their own problem areas by us helping them review the data and also giving them the infectious disease consultation.”

For example, a hospital might see from the data that it has an opportunity to improve its broad-spectrum antibiotic use in the ED.

“The [on-site] antimicrobial stewardship program committee will present [a plan] to their medical staff, and then they will implement the changes,” Vento said. “They will put forth new policies, and then monitor and track the results. We will stay as part of their committee from afar, taking part in their quarterly meetings or however often they want to meet.”

Certainly, the CDC and TJC standards provide an incentive to establish robust antimicrobial stewardship programs, but there are other, perhaps more important, incentives as well, Vento observed.

“These hospitals will be making improvements in individual and population-based care,” he said. “They will cut down on broad-spectrum antibiotic use and they will cut down on overall antibiotic use, and that is a win/win.”

REFERENCE

  1. Baggs J, Fridkin S, Pollack L, et al. Estimating national trends in inpatient antibiotic use among US hospitals from 2006 to 2012. JAMA Intern Med 2016;126:1639-1648.

SOURCES

  • Arjun Srinivasan, MD, Associate Director, Healthcare-Associated Infection Prevention Programs, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta. Email: beu8@cdc.gov.
  • Todd Vento, MD, MPH, Medical Director, FACP, FIDSA, Medical Director, Infectious Diseases Telehealth Services, Intermountain Healthcare, Salt Lake City. Phone: (801) 507-7000.